Your Partners in Providing Post-Discharge Care and Care Gap Closure
Our teams of medically trained professionals become your partners in care. Working as an extension of your staff, we provide patient touch points throughout a hospital stay and become a “safety net” during the critical 30-day post discharge care period.
Experienced nursing teams complement your efforts to improve outcomes and close gaps in care.
Personal interactions — not software — enable our post-discharge specialists to help hospitals, ACOs, and payers prevent readmissions and close care gaps.
Trusted by Leading Healthcare Systems
Engaging Patients to Reduce Readmissions
Creating relationships with patients helps us address social determinants of health, close care gaps, and reduce unnecessary readmissions.
How It Works
Engage Patients as Care Partners
- Empower patients through health literacy
- Partner on social determinants of health and preventative health measures
- Engage patients as partners in their own care to decrease the rate of avoidable readmissions
- Handle healthcare provider calls, texts, or emails at predetermined intervals to track patient recovery
- Provide medication reconciliation
- Connect care coordination to enhance the recovery process
Increase Quality Scores
- Create effective transitions to align with hospital quality measures throughout the episode of care
- Promote bi-directional patient-healthcare provider communication
- Focus on the metrics that improve HCAHPS scores over time
Prevent Avoidable Readmissions
- Manage patients to positive outcomes
- Track patients through timely interactions, building stronger patient-health partnerships
- Recognize and address social determinant barriers before readmission occurs
Trained to Simplify
Our experienced post-discharge care teams complement your teams and work as a safety net for patients.
Our services increase HCAHPS scores, reduce preventable readmissions, and support patient compliance with safety protocols and medication adherence. 365Telecare clinical teams are specially trained in motivational interviewing to ensure that patients understand all aspects of their discharge plan of care. A response of “always” to the Three-Item Care Transitions (CTM-3) questions leads to positive outcomes for patients and for our partners.
Simplifying Post Discharge
Post-discharge care is all we do. Our team of experienced care teams know how to complement a team without becoming yet another management problem. As a “safety net” for patients being discharged, we lessen the burden on staff, improve patient outcomes, uncover social determinants of health to reduce readmissions, and improve HCAHPS scores.
Healthcare System Success Stories
By accessing and compiling the database of readmitted billed DRGs, we were able to trend themes. One particularly strong theme in diagnosis led us to take a further dive into the data. This ultimately exposed an opportunity to repair a large educational gap. We launched a large-scale community educational initiative with our healthcare professionals leading the way.
We ultimately reduced our readmission rate, engaged our staff in community outreach, and most importantly improved the health of our community. Thank you 365 Telecare!